Understanding the Nature and Impact of PsA


Experts review the pathophysiology of psoriatic arthritis and share their perspective on how it can impact patients and caregivers.


Michele M. Cerra, MSN, FNP-C:My name is Michele Cerra. I'm a nurse practitioner at Duke University Medical Center in Raleigh, North Carolina. I am director of the Duke Rheumatology NP/PA (Nurse Practitioner/Physician Assistant) Fellowship Program. Joining me today is one of my colleagues for the discussion, Nancy Eisenberger. She is an FNP (family nurse practitioner), master’s prepared, and working on her doctorate. She works at Arthritis, Rheumatic, & Bone Disease Associates in Vorhees, New Jersey. Our discussion today will focus on the management of psoriatic arthritis, and how to ensure patient adherence and compliance as part of optimal patient care.

Let's get started. Nancy, when you think of patients who present in your practice with psoriatic arthritis, what are the main drivers we know that affect patients who are diagnosed with psoriatic arthritis, involving genetic factors, environmental, and the pathophysiology that's involved?

Nancy Eisenberger, MSN, FNP-C:Excellent question Michele. Our patients have an overactive immune system. It's an inflammatory arthritis, and originally, the markers we used to target were too close to factor out then. However, now we also know that IL-23 (interleukin-23) plays a huge role in psoriatic arthritis [and that] IL-17 plays some role. We even know that JAK (Janus kinase) inhibitors will benefit this, and our T-cell inhibitor medications also. Our patients come in with sore, swollen, tender joints, lots of swollen tendons, skin disease, they can have sausage digits; there's a lot of different ways they present when they come into us. They have a lot of pain; these patients experience depression. It's a very difficult disease.

Michele M. Cerra, MSN, FNP-C: I used to think rheumatoid arthritis was so common, and we know about 1.3 million people in the United States have rheumatoid arthritis, but currently there are about a million patients in the United States who have psoriatic arthritis. We know it's undiagnosed and patients are referred to us late in the disease state. And looking at those environmental and genetic factors, seeing if a virus or a bacteria has triggered it, seeing if they have genetic links to family history with psoriatic arthritis, educating our peers and primary care and our NPs and PAs who are in their school and learning about it—I don't think we get enough of it. That leads to patients who are diagnosed late, leading to more disability and joint deformity.

Nancy Eisenberger, MSN, FNP-C: Absolutely, Michele. Also, as we both experience at a clinic, you see that a lot of providers thought patients just had osteoarthritis because it looks very similar, and it is actually psoriatic arthritis. You can look at the thinning of the fingernails and things like that. You can help differentiate it, but it is a very challenging condition for people to diagnose sometimes.

Michele M. Cerra, MSN, FNP-C: Bringing up the nail thinning, it's so important for us to even educate dermatology, MPs (medical practitioners) and PAs, because here's where patients are seen, and they may have scalp disease and nail disease and we know those patients are the ones that go on to develop more moderate to severe psoriatic arthritis, and a quicker, earlier referral to rheumatology would benefit these patients in the long term. Taking a look at the uniqueness of this complex heterogeneous disease, we know as you said it can affect skin, it can affect their eyes, and they can have peripheral and axial involvement. This leads to a disease burden with comorbidities. When you take a look at these patients, they have cardiovascular disease, a nonalcoholic fatty liver, anemia, hypertension, metabolic disorders, even anxiety and depression. We know it's equal in men and women, but women tend to get burdened with "Maybe you're just suffering from anxiety and depression,” although we know that psoriatic arthritis, when it's underdiagnosed and missed, because of the enthesitis, dactylitis, sometimes patients are told "You know, you have plantar fasciitis and Achilles tendonitis, and it's just from overactivity.” It's really the main hallmark in the manifestations from psoriatic arthritis, so that anxiety and depression are being driven by their inflammation, their fatigue, and their poor sleep quality. How does it affect our patients' quality of life? What are you seeing in your practice as far as the comorbidities and their quality of life and how do you manage that?

Nancy Eisenberger, MSN, FNP-C: That's a very good point. As you said, with the depression, anxiety, [patients with psoriatic arthritis are] very often mistakenly diagnosed with just fibromyalgia, although they may have it as a comorbidity, because again, the entheseal points are very similar to tender points that are [found] in fibromyalgia. As we discussed, the other issue that we face is that there isn't a marker other than HLA-B27, (human leukocyte antigen B27). Only a very small percentage of patients with psoriatic arthritis will test positive for [it], so we don't have anything to go by, and very often, they do not have elevated inflammatory markers [or] anything like that. Patients come in in very poor shape. To educate these patients that it is a chronic progressive disease, that we must treat them in multiple ways as far as treating the inflammation, treating the mood, helping them get education, physical therapy when needed, sharing care with the dermatologist, all of this adherence to medication—these are all challenges that we have. Education is what it comes down to—and compassion and empathy.

Transcript edited for clarity.

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